Multidisciplinary Teams 1
A National Look at Elder Abuse Multidisciplinary Teams
Pamela B. Teaster, Ph.D.1 Lisa Nerenberg, M.S.W., M.P.H.2
Report for the
National Committee for the Prevention of Elder Abuse
Partner
National Center on Elder Abuse
The authors wish to thank the representatives of the multidisciplinary teams for their dedication to addressing the problem of elder abuse and their assistance with this project. 1
Vice President, National Committee for the Prevention of Elder Abuse and Assistant Professor, Ph.D. Program in Gerontology and University of Kentucky School of Public Health, 306 Health Sciences Building, 900 S. Limestone, University of Kentucky, Lexington, KY 40536-0200, 859.257.1450 ext: 80196 (telephone),
[email protected] 2
Consultant, National Committee for the Prevention of Elder Abuse,
[email protected]
Multidisciplinary Teams 2 Abstract Elder abuse multidisciplinary teams (MDTs) include professionals from diverse disciplines who work together to review cases of elder abuse and address systemic problems. MDTs reflect the understanding that clinical and systemic issues often exceed the boundaries of any single discipline or agency. Using an e-mail survey format, the authors received information from 31 MDT coordinators across the country representing fatality review teams, financial abuse specialist teams, medically oriented teams, and “traditional” teams. The coordinators provided information on the functions their teams perform, the importance of specific functions, cases reviewed, composition of teams, policies and procedures, administration, funding, and challenges to effective functioning. The most frequently performed functions are providing consultation aimed at assisting workers to resolve difficult abuse cases; identifying service gaps and systems problems; and updating members about new services, programs and legislation. When asked about the importance of these functions, responders ranked providing consultation aimed at assisting workers to resolve difficult abuse cases significantly higher than other functions. Teams expressed only mild concern for breaches in confidentiality. MDTs stressed the importance of input by professionals from the legal community for successful team functioning.
Key Words: multidisciplinary team, elder abuse, interdisciplinary team, financial abuse, fatality review, coordination
Multidisciplinary Teams 3 A National Look at Elder Abuse Multidisciplinary Teams
Multidisciplinary teams (MDTs), groups of professionals from diverse disciplines who come together to review abuse cases and address systemic problems, are now a hallmark of elder abuse prevention programs. Teams first emerged in the early 1980s in recognition of the fact that clinical and systemic issues that abuse cases frequently pose exceed the boundaries of any single discipline or agency. Teams are believed to offer many benefits to professionals, clients, and communities. In addition to helping individual service providers resolve difficult cases, the team review process has been credited with enhancing service coordination by clarifying agencies’ policies, procedures, and roles and by identifying service gaps and breakdowns in coordination or communication. Teams may also enhance members’ professional skills and knowledge by providing a forum for learning more about the strategies, resources, and approaches used by multiple disciplines. The rapid proliferation of MDTs across the United States and Canada in the last two decades has been accompanied by a growing demand for highly specialized expertise in such areas as financial abuse, fatality review, and medical issues. Federal, state, and local governments have increasingly acknowledged the importance and benefits of MDTs and have responded by providing resources, technical assistance, and statutory authority. Currently, there is a paucity of research examining elder abuse MDTs. The research that does exist is localized, focuses on team development, and highlights the benefits of MDTs (Manitoba-Seniors-Directorate, 1994; Wasylkewycz, 1993; Wolf, 1988). Research does not address the functions and composition of MDTs and is not national in scope. Although anecdotal evidence suggests that teams offer tangible benefits to their members and communities, in-depth studies to identify how they function and demonstrate their impact on the problem of elder mistreatment have not been conducted. To begin to shed light on the functioning of teams, the National Committee for the Prevention of Elder Abuse (NCPEA), as partner in the National Center on Elder Abuse (NCEA), carried out a national survey. Team representatives were asked to identify key features of teams, explain variations, describe specialized teams, and identify common obstacles and how they are being addressed. The information presented
Multidisciplinary Teams 4 below provides a picture of the various types of teams that responded to the survey. Further, it provides a framework for decision-making for groups that are considering starting teams or enhancing existing teams, and sets the stage for future research on teams’ impact and effectiveness. Methods Because no national list of MDTs was available, the authors requested the help of NCPEA’s Board of Directors and subscribers to NCEA’s list serve (operated by the American Bar Association’s Commission on Law and Aging) to identify and suggest elder abuse teams. The request yielded approximately forty recommendations. The authors did not provide a specific definition of teams in order to capture a wide variety. However, they attempted to include teams that represented a diverse mix in terms of size of membership, focus, geographic location, and length of time in existence. The sample included “traditional” MDTs as well as specialized teams including financial abuse specialist teams (FASTs), teams with a medical orientation, and fatality review teams. After approval by the University of Kentucky’s Institutional Review Board, the authors sent e-mail letters to representatives or spokespersons of 40 teams. The e-mail communication explained the project, invited representatives of MDTs to participate, and advised potential participants of project timelines and processes. Thirty-two (32) team coordinators indicated their willingness to participate, and the project group sent out 32 surveys to them. Coordinators were given two weeks to complete the surveys and return them via e-mail, fax, or conventional mail. At the end of that period, members of the project group made follow-up calls to ensure the highest possible response rate. Of the original 40 team coordinators contacted, thirty-one returned surveys, for a response rate of 77.5%. Data Collection Instrument The survey instrument (Appendix A) was developed in consultation with members of NCPEA’s Board of Directors to elicit information on defining features of teams such as sponsorship, funding sources, formalized policies and agreements, and membership. Respondents were also asked to identify challenges MDTs encountered as well as successful resolutions. They were further asked to describe products and accomplishments. Prior to sending the survey to the entire group, it was pilot tested with
Multidisciplinary Teams 5 two team coordinators, whose suggestions were then incorporated into the final survey that was sent to respondents. Raw data were entered by a doctoral level graduate student in the Ph.D. Program in Gerontology at the University of Kentucky and cross-checked for accuracy with the assistance of another doctoral level gerontology student. The doctoral level assistant contacted respondents for clarification when questions arose regarding the information provided on the survey. Data were analyzed by faculty and graduate students at the University of Kentucky using descriptive statistics. Results Functions of Teams To identify the most frequently performed functions of MDTs, respondents were given a checklist and asked to indicate those they perform. They were also invited to add additional functions. The two most frequently cited functions of teams (Table 1) were providing expert consultation to service providers and identifying service gaps and systems problems (93.5% each). Nearly all teams also update new members about services, programs, and legislation (90.3%). Well over three-fourths of teams perform the following additional functions: advocating for change; planning and carrying out training events; and planning and carrying out coordinated investigations or care planning. Table 1 Functions of the Team ________________________________________________________________________ Functions
n
%
________________________________________________________________________ Providing expert consultation to service providers
29
93.5
Identifying service gaps and systems problems
29
93.5
Updating members about new services, programs, legislation
28
90.3
Advocating for change
26
83.9
Planning and carrying out training events
26
83.9
Planning and carrying out coordinated investigations or care planning 25
80.6
Multidisciplinary Teams 6 Respondents were given the opportunity to list additional functions and added the following: providing training to team members on techniques, developing a coordinated community response to older victims of domestic violence and elder abuse victims, encouraging the investigation and prosecution of elder abuse crimes, resolving difficult health and social problems, cutting through delays that are built into ‘the system,’ and providing an opportunity for colleagues to offer support and advice on such issues as setting boundaries with clients and counter-transference. Importance of Team Functions In addition to identifying frequently performed functions, respondents were asked to rate the importance of each function on a one to five scale (with one being of no importance and five being essential). The highest ranking function was “providing expert consultation to service providers,” which was rated as “Very Important” or “Essential” by 71% of respondents (Table 2). Table 2 Teams’ Ranking of Functions as Very Important/Essential
Functions
n
%
Providing expert consultation to service providers
22
71.0
Updating members about new services, programs, legislation
18
58.1
Identifying service gaps and system problems
17
54.9
Planning and carrying out coordinated investigations or care planning
16
51.6
Planning and carrying out training events
14
45.2
Advocating for change
11
35.5
Approximately half the teams ranked as “Very Important” or “Essential” the following functions: updating members about new services, programs, and legislation; identifying service gaps or systems problems; planning and carrying out coordinated investigations or care planning; and carrying out training events. As was the case with the earlier question, respondents were invited to list additional functions and to indicate their importance. Ranked as “Essential” were providing training to team members on
Multidisciplinary Teams 7 techniques, developing a coordinated community response to older victims of domestic violence and elder abuse victims, and encouraging investigation and prosecution of elder abuse crimes. Types of Cases Reviewed Most MDTs conduct case reviews, but they may handle the review process quite differently. For example, some teams review all types of elder abuse cases, while others focus on certain types. Nearly three-fourths (71.0%) review cases involving all types of abuse and neglect. Seven teams (22.6%) focus on financial abuse cases. Of these, five described themselves as Financial Abuse Specialist Teams (FASTs), a model developed in Los Angeles in the early 1990s and since replicated in other communities. Despite the common name, there are wide variations among the FASTs. For example, one FAST meets every two weeks, only includes representatives from public agencies, and places an emphasis on its rapid response to deter abuse and preserve assets. Another FAST has over 50 members, includes representatives from many private, non-profit agencies, and meets quarterly. One team in the sample identified itself as a “fatality review team,” a model that was originally developed in the fields of child abuse and domestic violence to review suspicious deaths or “near-deaths.” Five additional teams indicated that they review fatalities but did not specifically call themselves fatality review teams. Two teams focused on medical issues in cases involving clients with multiple medical problems or cognitive decline. Several teams indicated that they focus on particularly problematic cases, such as self-neglect cases, cases involving persons with mental illness and mental retardation, high-risk situations, and cases in which guardianship is being considered. Although many of the teams address systemic problems and issues, two teams indicated that they focus exclusively on systemic issues (as opposed to clinical issues related to client care). Team Attendance Respondents were asked to indicate how many people regularly attend team meetings. The question was posed in this way (as opposed to asking for number of members) because teams that operate informally may welcome all interested professionals to attend and do not require them to sign membership agreements. Nearly
Multidisciplinary Teams 8 half (45.2%) of the teams have an average attendance of between five and 10 people. Just over one-quarter (25.8%) routinely have between 10 and 20 participants, nearly a tenth (9.7%) have between 20 and 30 people attend regularly, and nearly a tenth (9.7%) routinely draw more than 30 participants. One team typically has fewer than four in attendance (3.2%). Two teams did not respond to the question (6.5%). Attendance Requirements. A fourth of MDTs (25.8) require members to attend a certain number of meetings yearly (e.g., five to ten). Three teams indicated that missing a certain number of meetings (e.g., three consecutive meetings) is grounds for dismissal. Typically, team members are encouraged to provide alternative attendees in their absence if they are unable to attend. Frequency of Meetings. Nearly three-fourths of MDTs (74.2%) meet monthly (9.7% meet every two weeks, 9.7 % meet every other month and 3.2% meet quarterly). One Team (3.2%) meets as needed in addition to its regularly scheduled meetings. To streamline meetings, some teams have structured agendas, which include such items as introductions, reviews of confidentiality, guest speakers or educational presentations, and updates on services or developments in the field. Categories of Membership MDTs were asked specific questions about their members. Teams reported that they recruit individual members, invite agencies to join and to designate representatives, or both. Individual members participate for their own benefit and represent their own viewpoints or perspectives, while agency members may serve as liaisons between their organizations and the team, convey agency policy and perspectives, and commit resources. Well over half of the teams (64.5%) allow individuals to join regardless of agency affiliation. Organization members include private non-profit agencies, public agencies, and for-profit agencies (including professionals in private practice). Some teams only permit non-profit agencies and individuals who work for non-profit agencies (61.3%) to join. Slightly over one-third (35.5%) permit for-profit businesses to participate. Two teams only include representatives from public agencies. Certain teams have created special categories of membership. For example, some have “core member” (e.g., APS, or law enforcement), categories that must be filled at all
Multidisciplinary Teams 9 times, and other categories that are considered desirable but not required. Teams may extend certain benefits to some members and not others, including the right to present cases (Table 3). Over half (58.1%) permit any team member to present cases, while others (29.0%) only allow certain members to do so (one team only permits APS workers to present cases, and another permits APS, Ombudsmen, law enforcement, and private attorneys to present). Still others (25.8%) allow any service provider in the community to present cases, regardless of whether or not they are members. Table 3 Members Allowed to Present Cases
Case Presenters
n
%
Any team member can present a case
18
58.1
Certain members can present cases
9
29.0
Any service provider, regardless of membership can present
8
25.8
Note: Multiple responses were given for this question. Respondents indicated that the responsibilities of members also vary. For example, some teams require certain members to provide additional consultation or training between meetings and another uses “technical advisors” who do not routinely attend meetings but who are called upon for assistance as needed. Disciplines Represented Respondents were asked to indicate what professional disciplines are represented on their teams (Table 4). The most commonly cited were police and sheriffs, which was listed by 93.5% of respondents. APS workers participate on 83.9% of teams. Disciplines included on more than half of the teams are: providers of geriatric mental health services, prosecutors, aging service providers, public guardians, and domestic violence advocates. Other disciplines represented on fewer than 50% of teams include nurses, physicians, non-geriatric mental health professionals, and victim-witness advocates. Approximately a third (32.3%) include representatives from financial institutions, and another third (32.3%) include clergy. Just over one-quarter (25.8%) include retired professionals.
Multidisciplinary Teams 10 Table 4 Professionals Represented on Teams
Disciplines
n
%
Police/Sheriff
29
93.5
Adult Protection Services
26
83.9
Geriatric Mental Health Services
25
80.6
Prosecutors
22
71.0
Aging Service Providers/Public Guardians
20
64.5
Domestic Violence Advocates
16
51.6
Nurses
15
48.4
Physicians
13
41.9
Non-Geriatric Mental Health Professionals
13
41.9
Victim-Witness Advocates
13
41.9
Representatives from Financial Institutions
10
32.3
Clergy
10
32.3
8
25.8
Retired Professionals
Respondents were invited to list other disciplines and service categories included on their teams, and over half (51.6%) did so. These included ethicists, animal care and control officers, public administrators, probation and parole personnel, code enforcement personnel, resource specialists, fire fighters, a retired judge, housing managers, housing advocates, personnel from assisted living facilities, members of public utility boards, inhome service providers, realtors, representatives from state long-term care licensing and regulatory agencies, hospital social workers, emergency medical personnel, providers of services for persons with developmental disabilities, media representatives, homeless shelter staff, health department personnel, health statistics specialists, health advocates, and certified public accountants.
Multidisciplinary Teams 11
Level of Team Formality Respondents were asked several questions about formalized policies and procedures they employ and written materials they use to document or support policies and procedures, including meeting summaries, memoranda of understanding, “job descriptions” for members, orientation materials, policy and procedures manuals, and membership categories. These are described below (Table 5). Proceedings of Meetings. Over half (54.8%) of MDTs produce written records of meetings, which may be in the form of “minutes,” summaries of the proceedings or case reviews, and recommendations. One team uses genograms to graphically depict the content of the team review (charts that graphically describe the social and familial relationships between individuals, a technique primarily used by mental health professionals to help identify positive and negative influences affecting an individual). Teams that produce written records of meetings vary in how they use and disseminate them. Over half (51.6%) disseminate information on case reviews to team members and others. One MDT disseminates minutes to members but excludes information on case reviews, while another sends minutes to non-members in addition to members (including all police departments in the county, the district attorney, the Sheriff’s Department, state adult protection, the public administrator, and a legal center for handicapped and older adults) as a way to educate these groups about the issue. A medical team includes case review summaries in clients’ medical charts. One team that produces minutes keeps them in a special team book maintained by the program coordinator, who provides summaries upon request. Contracts and Memoranda of Understanding. Just over half (51.6%) of MDTs require members to sign contracts or memoranda of understanding, which typically include provisions for confidentiality and terms of membership. Over a fourth of teams (29.0%) require agency supervisors or administrators to sign contracts or memoranda of understanding, affirming the agencies’ commitment to assign representatives and to replace representatives who are unable to meet their commitments.
Multidisciplinary Teams 12 Table 5 Level of Team Formality Method
n
%
Summarized Proceedings
17
54.8
Contracts/Memoranda of Understanding
16
51.6
Case Review Guidelines
16
51.6
Policy and Procedures Manuals
10
32.3
Job Descriptions
9
29.0
Orientation Manuals
9
29.0
Term Limits
7
22.6
Guidelines for Review of Cases. Just over half (51.6%) of teams use case review guidelines to provide direction or suggestions to presenters on what information to include in case presentations and the order in which to present it. Typically included are the client’s living arrangement, support network, functional status, a description of the abuse and/or other presenting problems, and a history of attempted interventions or services. Policies and Procedures Manuals. Approximately a third (32.3%) of teams indicated that they have formal policies and procedures manuals. Only one team keeps the manual on disk rather than having it in hard copy due to the sensitive nature of its contents. Job Descriptions. Over a fourth (29.0%) use job descriptions for members, which may be contained in membership agreements, member handbooks, or elsewhere. The state of Wisconsin has developed a manual for its counties that includes job descriptions for representatives from the fields of law enforcement, medicine, law, domestic violence, financial management and mental health, as well as clergy. In addition to outlining the specific duties and responsibilities of each representative, Wisconsin’s job descriptions also contain detailed requirements with respect to education, experience, training,
Multidisciplinary Teams 13 knowledge, skills, and abilities. For example, it is recommended that law enforcement representatives have associates’ degrees in criminal justice or another social science. Orientation Materials. Approximately a fourth of teams (29.0%) use orientation materials, which usually include handbooks that contain general information on elder abuse, pertinent laws, research articles, policies, mission statements, confidentiality agreements, by-laws, etc. One team has produced a video that all new members must view. Term Limits. Nearly a fourth (22.6%) of the teams have term limits for members, the most common of which is one year. The majority of teams (77.4%) allow members to serve more than one term. An annual renewal process may serve as an opportunity to review members’ participation during the year and determine whether they have met their obligations to the MDT. Other Information. Other written materials used by teams include a handbook for coordinators and written protocols. Some teams solicit input from members through routine or occasional surveys that ask how useful meetings are to members or by requesting suggestions for educational presentations. They may further ask members to provide information about case outcomes (e.g., were prosecutions successful as a result of team interventions; were assets or property recovered and, if so, what was the amount). Team members may be asked to indicate how many hours they have contributed during and between meetings and to estimate their associated pro bono contributions. Some teams ask members to fill out feedback forms at the end of every meeting. Administration MDTs were asked to provide information about administration. Four teams (12.9%) were coordinated by an Area Agency on Aging, and APS administered 10 (52.6%) teams. Other arrangements included administration by a district attorney’s office or in collaboration with agencies/organizations such as a university, a local nonprofit, or sheriff’s office. Some operate informally without designated administrators. Activities associated with team administration that were cited included producing and sending out agendas, meeting announcements and minutes; arranging for meeting space; recruiting members and negotiating contracts and memoranda of understanding; preparing materials such as handbooks and job descriptions; producing and disseminating
Multidisciplinary Teams 14 minutes; selecting cases; serving as a focal point for questions; and, in the case of some teams, following up on members’ recommendations. Leadership Adult Protective Services (APS), the agencies mandated to respond to reports of abuse, neglect, and exploitation of older adults in most states, play a prominent role in MDTs. Nearly one-third of teams (32.3 %) are administered by APS programs alone or in collaboration with other agencies (e.g., one team involves collaboration between APS and a hospital-based geriatric program). Following APS, Area Agencies on Aging (AAAs) (12.9%) are the next most likely entity to administer teams. Just over half (51.6%) of the teams surveyed are administered by other agencies. These include a county attorney’s office, a private non-profit agency, a state attorney general’s office, a university, and an “elder abuse provider” agency. Funding and In-kind Support MDTs were asked to describe their sources of funding and in-kind support. The most common source of support to teams is APS programs, which provide support to 38.7% of the teams surveyed. Most APS support is in-kind (92.0%), which includes staff time (this may be for case workers, supervisors, support and clerical staff), meeting space, and the printing and mailing of materials. A fourth of APS programs (25.0%) provide funding, with amounts ranging from $70 to $250. Area Agencies on Aging (AAA) are the second most common source, providing support to 32.3% of the teams (again, most support is in-kind). Monetary support from AAAs includes elder abuse funds authorized under the Older Americans Act. Dollar amounts ranged from $3,000 to $85,122 annually. Nearly a half of MDTs (48.4%) receive support from other sources. Monetary support is provided by a state department of public safety, a state justice assistance council, the American Association of Retired Persons (AARP) and foundations. Funding amounts from these sources ranged from $500 to $10,000 yearly. Sources of additional in-kind support included an attorney general’s office, a college of medicine, a county hospital district, a state attorney, providers of mental health and medical services, law enforcement, and a medical examiner’s office.
Multidisciplinary Teams 15 Calculating the costs of operating a team was complicated by the fact that few teams have dedicated staffing. Staffing tasks are often shared by several individuals, are likely to fluctuate over time, and may be carried out intermittently and in concert with other tasks. Comparing costs was further complicated by the fact that teams engage in such diverse activities as community outreach, professional training, and research, all of which require very different levels of support. In addition, those that rely on in-kind support typically do not track costs. Consequently, teams’ responses to questions about their costs varied widely, with some stating that there were no costs associated with the team, with one team indicating that it operates on an annual budget of over $85,000. Other MDTs were unable to respond to the question. Sources of Technical Assistance Teams receive guidance and technical assistance from a variety of sources, the most common of which is state agencies. State units on aging, state APS programs, and offices of attorneys general provide assistance to approximately one-third (32.3%) of the teams surveyed. These agencies provide manuals, sample materials, and training. Examples include the Illinois Department of Aging, which creates resource materials, brochures, posters, and videos. Other sources of technical assistance include national organizations (9.7%), such as NCPEA, which operates a program of local affiliates, and a statewide coalition of teams. Challenges MDTs have encountered numerous challenges. Respondents were asked to provide information about these challenges and to describe the initiatives they have taken to address them (Table 6).
Multidisciplinary Teams 16 Table 6 Challenges That Teams Face Challenges
n
%
Lack of Participation by Certain Disciplines
15
48.4
Maintaining an Adequate Number of Cases
7
22.6
Failure of Certain Groups to Present Cases
5
16.1
Confidentiality
4
12.9
Animosity Among Members
3
9.7
Failure to Agreed Upon Follow-Through
3
9.7
Members’ Feeling Times Is Not Well Spent
2
6.7
Lack of Participation By Certain Disciplines. Half (48.4%) of the teams indicated that they experienced difficulty gaining or maintaining participation by certain disciplines. Foremost among these was law enforcement (42.9%). Other underrepresented disciplines include medical professionals, clergy, prosecutors, attorneys, representatives from financial institutions, providers of services to young disabled adults, pharmacists, state long-term care licensing and regulatory agencies, county attorney's offices, and mental health workers. Maintaining an Adequate Number of Cases. Nearly a fourth of teams (22.6%) indicated that they have trouble finding enough cases to present. One reason cited was that APS staff members are too busy to prepare case summaries. In addition, many communities now have more than one team, which creates “competition” for cases. Teams have attempted to increase the number and diversity of cases by sending out email reminders about meetings and, in communities with more than one team, clarifying the types of cases reviewed by each. Confidentiality. Although the researchers had anticipated that breaches in confidentiality would be a major concern of teams, only four respondents (12.9%) indicated that this was a challenge for them. Respondents were also asked to indicate if they had, in fact, experienced breaches. Only one team reported experiencing a “close
Multidisciplinary Teams 17 call.” This relatively moderate level of concern may reflect teams’ satisfaction with measures they have taken to preserve confidentiality. Measures that MDTs have taken to ensure confidentiality included confidentiality agreements, which are employed by well over half (64.5%) of the teams and the use of pseudonyms or initials when discussing cases (48.4%). Over a third of teams (35.5%) operate in states that have special laws that permit the sharing of information and/or immunity laws, which protect information disclosed at meetings from being used as evidence in civil actions or disciplinary proceedings. Other methods for ensuring confidentiality included written reminders about confidentiality (with applicable state code sections) on monthly meeting agendas, outlining confidentiality provisions in a memorandum of understanding members sign when they join the team, and not disseminating case summaries. One respondent observed that as teams gain experience and members get to know each other, concerns about confidentiality have decreased. Other Challenges. Other challenges cited included the failure of certain groups to present cases (16.1%), animosity among members (9.7%), failure of members to follow through on actions to which they have agreed (9.7%), and members not feeling their time is well spent (6.7%). Additional challenges cited by single respondents included: agency representatives delegated to attend meetings do not have the authority needed to make systems changes, and those with the authority do not attend, lack of funding and support, and failure to achieve “buy-in” from members whose participation is not voluntary (e.g., they are mandated to participate). Tangible Products In addition to case reviews, teams engage in many other activities, the most common being those related to training (58.1%). Training materials produced by teams include booklets, packets, manuals, PowerPoint presentations, and a curriculum and workbook. Groups targeted for training include bank employees, clergy, gatekeepers, the public, law enforcement, medical students and practitioners, and mandated reporters. Training events include conferences, workshops and “train-the-trainer programs.” Topics covered in training sessions include fraud prevention, medical issues, APS and its role in receiving reports (including services offered, who must report, and what to expect once a case has been assigned to APS for investigation and follow-up), how to recognize and
Multidisciplinary Teams 18 investigate fiduciary abuse, real estate fraud, and how to gather evidence of incapacity for guardianships and lawsuits. Approximately one-third of MDTs (32.3%) produce other materials (not related to training) including brochures, laminated law enforcement cards that list elder abuse statutes, resource cards for law enforcement, a video on victim impact, a video on FAST, websites, annual reports, newsletters, resource guides, public service announcements, and handbooks. Replication materials produced by teams include videos and how-to manuals. Other activities and accomplishments cited by respondents included the development of interagency agreements (25.8%), legislation (19.4%), a protocol for law enforcement, and referral guidelines for APS workers. One team was developing a volunteer program to recruit retired bank personnel to assist in investigating financial abuse cases. The program is patterned after a successful model developed in Oregon. Conclusions This study was a first effort to shed light on the role, processes, varieties and accomplishments of MDTs on a national level. Although limited in sample size (it did not study the hundreds of teams that have emerged nationwide in the last two decades), it underscores the benefits and costs of teams, highlights trends, and provides insight into the challenges teams face. Further, it reveals some of the difficulties program planners and policy makers address in anticipating the direct and indirect costs of operating teams. Several findings are noteworthy. Assisting workers resolve difficult abuse cases is frequently cited as the primary goal of teams and is why some teams were initiated. Although this function was rated as the most important performed by teams, the overwhelming majority of teams also identify service gaps and update members about new services, resources, and legislation. This finding suggests that, although case reviews are important in themselves, as previously believed, they frequently reveal systemic problems and point to the need for new services, resources, legislation, and information about new resources and developments. Also noteworthy is the importance of legal expertise and input on teams. Police and sheriffs, prosecutors and public guardians are among the six most commonly
Multidisciplinary Teams 19 included disciplines represented on teams, surpassing such groups as medical professionals and domestic violence advocates. The relatively mild concern for breaches in confidentiality was also surprising in light of anecdotal evidence to suggest otherwise (i.e., a fatality review team in California refrained from reviewing cases until the state passed legislation that permitted the sharing of information). Reported costs of operating teams varied widely, with some teams clearly not knowing their true operational costs, although it was obvious that costs were incurred. It may be that teams should examine, through systematic outcome evaluation, their true costs and benefits at regular intervals to determine whether they meet their operational goals or whether such goals can be reasonably achieved. In conclusion, MDTs play a key role in communities’ response to elder abuse and are highly valued by those who participate. Among the benefits they cited were strengthening community relationships, eliminating or ameliorating turf wars, promoting team work and cooperation, providing assistance on cases referred for guardianship, helping clients secure improved medical care, and enhancing members’ understanding of services. Clearly, the strength of MDTs is their ability to mobilize professionals from a wide range of disciplines to confront the complex and growing problem of elder mistreatment.
Multidisciplinary Teams 20 References
Manitoba-Seniors-Directorate. (February 1994). Abuse of the elderly: a manual for the development of multidisciplinary teams. MDT Working Group on Elder Abuse, Winnipeg, Canada. Wasylkewycz, M.N. (1993). Elder Abuse Resource Centre, a coordinated community response to elder abuse: One Canadian perspective. Journal of Elder Abuse and Neglect, 5, 21-33. Wolf, R. S. (1988). Elder abuse: Ten years later. Journal of the American Geriatrics Society, 36, 758-762.
Multidisciplinary Teams 21 Appendix A
Questionnaire on Multidisciplinary Teams
National Committee for the Prevention of Elder Abuse
Thank you for agreeing to participate in a study of Multidisciplinary Teams (MDTs) being conducted by the National Center for the Prevention of Elder Abuse (NCPEA). Please complete this questionnaire to the best of your knowledge (you are welcome to add rows to the tables or provide additional information at the end of the survey) and return it by October 4, 2002 to Pamela Teaster by e-mail:
[email protected] or fax: 859.323.2866. Should you need clarification regarding the questions asked, please contact: Pamela B. Teaster: Ph: 859.257.1412 x484, e-mail:
[email protected] Fax: 859.323.2866 CONTACT INFORMATION: Name of Team: _____________________________________________________ Completed by:_______________________________________________________ Title and Affiliation:__________________________________________________ Telephone Number: ___________________________________________________ E-mail Address: _______________________________________________________ 1. Functions of the Team. Please rate the importance of the following functions of your team by checking the appropriate box. Use the following scale, and please make comments or indicate that the function is not applicable. (1) = No Importance, (2) = Somewhat Important, (3) = Important, (4) = Very Important, (5) = Essential
Function(s) Provide expert consultation to service providers Plan and carry out coordinated investigations or care planning Identify service gaps/systems problems Advocate for needed change (e.g., funding for services) Plan and carry out training events Keep members up to date about new services and programs, legislation,
(1)
(2)
(3)
(4)
(5)
Comments or Not Applicable (NA)
Multidisciplinary Teams 22 services, etc. Other (specify) 2. Types of Cases Reviewed. Some teams have a special focus. They may address certain types of abuse only, certain types of clients, or certain aspects of cases. What type of abuse cases does your team discuss? ( Check all that apply, and please make comments). (√ )
Type(s) of Cases Reviewed All types of abuse and clients Exclusively financial abuse cases Fatalities High risk cases Team focus is on medical aspects of cases Other (specify)
Comments
3. Case Presentor(s). Who can present a case? (Check all that apply, and please make comments). (√ )
Case Presentor(s) Anyone in community Team members Only certain members (specify)
Comments
4. Level of Formality. Some teams have special procedures or resources. (Check all that apply, and please make comments). (√ )
Level of Formality Comments Contracts or memoranda of understanding with members Contracts or memoranda of understanding with members’ agencies Job descriptions detailing the roles of consultants Guidelines for case reviews Term limits (if yes, please specify) Orientation materials (if yes, please specify) Policy and procedures manual Proceedings of meetings are summarized in writing Proceedings of meetings are summarized and disseminated to members Membership categories (e.g. only certain people can present cases) Other (specify)
Multidisciplinary Teams 23 5. Administration. Who coordinates your MDT? (Check all that apply, and please make comments). (√ )
Administration Comments Area agency on aging APS City or County funds More than one agency operates the team (specify) Other agencies (specify)
6. Funding and In-kind Support. Please indicate the sources of funding and in-kind support for your team. Types of support may include funding, staffing, meeting space, etc. (√ )
Source of Support
Monetary (indicate amount)
In-kind (specify)
Area agency on aging APS Other Community Agency (please specify) 7. Sources of Technical Assistance. Does your team receive on-going support or technical assistance from any of the following? (Check all that apply and please specify where possible). (√ )
Source of Technical Assistance National organizations (specify) State agency (specify) State coalition (specify) Other (specify)
Agency and Type of Assistance
8. Confidentiality. How does your team ensure confidentiality? (Check all that apply, and please make comments). (√ )
Confidentiality Comments We don’t use the names of clients being discussed Team members sign a confidentiality statement State law allows for the sharing of information Other (please specify)
Multidisciplinary Teams 24 9. Members. Who can join the team? (Check all that apply, and please make comments ). (√ )
Members Individuals Non-profit agencies For-profit agencies
Comments
10. Member Affiliation. (Check all that apply, and please make comments). (√ )
Member Affiliation Comments APS Aging service providers Public guardians Police and/or Sheriffs Prosecutors Domestic violence advocates Mental health professionals for the elderly Mental health professionals for the non-elderly Personnel from financial institutions including banks, brokerage houses, savings and loans Clergy Physicians (specify type) Nurses Victim Witness assistance advocates Retired professionals Other (specify)
11. Attendance. Estimate, to the best of your ability the average number of people who attend meetings. (Check all that apply, and please make comments). (√ )
Attendance Fewer than 4 Between 5-10 Between 10- 20 Between 20 – 30 More than 30
Comments
Multidisciplinary Teams 25
12. Frequency of Meeting. How often does the team meet? (Check all that apply, and please make comments). (√ )
Frequency Weekly Every two weeks Monthly Every other month Quarterly As needed Other (specify)
Comments
13. Challenge(s). What challenges has your team encountered? (Check all that apply, and explain the significance of the challenge). (√ )
Challenge(s) Comments Lack of participation by certain groups (specify) Client confidentiality was breached Members have concerns that confidentiality will be breached Private practitioners have used meetings to market their services Members do not participate regularly Animosity between members Lack of follow-through by members Lack of cases Certain groups fail to present cases Members don’t feel time is well spent Other (specify)
14. Contract Provisions. Does your team have a contract for members? (If yes, check all that apply, and please make comments. If no, continue to Question 15). (√ )
Contract Provisions Comments Requirements to attend a certain number of meetings Membership terms (length of time) Confidentiality Commitment to provide consultation outside of meetings Prohibitions against using meetings to market services Other (specify)
Multidisciplinary Teams 26
15. Tangible Products. What tangible products has your team produced? (Check all that apply, and please make comments). (√ )
Tangible Products Comments Sponsored or worked with legislators to sponsor legislation (specify) Organized a training event (specify) Developed materials, brochures, etc. (specify) Conducted a needs assessment Developed interagency agreements or protocols Other (specify
16. Evaluation. Has your team ever been evaluated? If yes, please specify.
17. Materials Created. Please list resource materials that you have created for team members or other community groups.
18. Other. Please use the space below (and feel free to add pages) to make any other comments that you would like to make about your Multidisciplinary Team.
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